Consumer Complaint Form

SECTION A
Notice: Under the Public Information Act, this complaint and
the complainant's identity are subject to disclosure.

You, as the complaining party

I represent:

First Name:

Last Name:

Company Name:

Mailing Address:

City:

State:

Zip:

Telephone
Numbers:
###-###-####

Work: Home: Cell:
Fax:

Email Address:

SECTION B

Manufacturer

Name:

Address:

City:

State:

Zip:

Telephone
Numbers:
###-###-####

Work: Fax:

Retailer

Name:

Address:

City:

State:

Zip:

Telephone
Numbers:
###-###-####

Work: Fax:

Installer

Name:

Address:

City:

State:

Zip:

Telephone
Numbers:
###-###-####

Work: Fax:

Other

Company Name:

First Name:

Last Name:

Address:

City:

State:

Zip:

Telephone
Numbers:
###-###-####

Work: Fax:

SECTION C
Please state the nature of the complaint
Character Limit: 4000 Characters Remaining: 4000

SECTION D
Home Information, if applicable

Home Sections:

	HUD Label or Texas Seal*	Serial Number	Width	Length
1
2
3
4

* HUD Labels and Texas seals can be found on a data plate attached to the back end of the
home, opposite the tow bar end. Labels and seals are 10 characters long with a three
letter prefix followed by 7 digits, such as TEX0000000. Do not include any dashes in the
number. Each section of the home will have a different number.

Manufacturer Name:

Model Year:

Model Name:

Physical Address
of Home:

City:

State:

Zip:

County where
home is located:

Date Installed:

mm/dd/yyyy

Purchase Date:

mm/dd/yyyy

Purchased New Puchased Used

Was home purchased by itself (as personal property) or with land (as real property)?

Personal Real

Do you have a title or a Statement of Ownership and Location in your name?

Yes No

Specific instructions
or directions to
location of home

Character Limit: 4000 Characters Remaining: 4000

By submitting this complaint you swear, under penalty of perjury, that the matters
set forth in this complaint are, to the best of your knowledge, true and correct.

Copyright © 2016 Texas Department of Housing and Community Affairs
For assistance with this system, please contact Manufactured Housing Customer Service at 1-800-500-7074 or email complaints@tdhca.state.tx.us.